Collaboration, Connection and a Strengths-based Approach to Suicide Prevention

• 1. Collaboration,ConnectionandA StrengthsbasedApproachtoSuicide Goal3oftheTheNewZealandSuicidePreventionStrategyPrevention(AssociateMinisterofHealth,2006)focusesonimprovingthecare ofpeoplewhomakenonfatalsuicideattempts. Itsuggestsdevelopingpolicies,strategiesandservicesthatleadto bettertreatment,managementandaftercaresupportforthose makingnonfatalsuicideattempts. Itoutlinesareasofactionincluding: Improvingmethodsoftreatment,management,aftercareandsupport ChrisBowden Improvingquality,continuityandaccessibilityofcare Lecturer,SchoolofEducationStudies,Victoria Supportingfamilies/whnautocareforsomeonewhohasmadeUniversityofWellington.asuicideattempt Chris.Bowden@vuw.ac.nz DevelopingbetteraftercareandsupportsystemsforMoriwhohavemadeasuicideattempt. 21Nov2007SPINZ2007Symposium:BuildingtheJigsaw CollaboratingforSuicidePreventionTheNeedtoImproveServices,Connect WithandEngageYouthImprovingServices Buston(2002)echoesthesegoalsinherstudyofadolescentusers Hickie,Fogarty,Davenport,Luscomb&Burns(2007)ofmentalhealthservices. identifysomeofthekeychallengesinvolvedin Sheclaimsthatfurtherattentionneedstobegiventothedevelopingnewyouthappropriateprimarycaredevelopmentofempathiccommunicationskillsbyhealthservices:professionalsworkingwithyoungpeoplewhoareexperiencingmentalhealthproblems. Increasingyoungpeoplesaccesstosuchservices.Theimportanceofsupport,empathyandaccessibilitywere Providingthestyleofservicesthatyoungpeoplemostseek.repeatedlystressedbyrespondents(Buston,2002,p.240). Focusingworkforcetraininganddevelopmentlargelyonearly interventionmodels. Shealsohighlightstheneedforhealthprofessionalstoworkon Providingevidencebasedpsychologicalandmedicalservices.connectingwithyoungpeopleinawaythatencouragesthemtoremainengagedwithservices: Hickieetal(2007)recognisetheimportanceofFurtherdevelopmentbycliniciansofamannerwhichencourages developingintegratedcollaborativecaremodelsamongthepatienttoopenupandwhichgivestheimpressionofcaring,empathyandbeinglistenedto,shouldnotbeunderestimated someofthesolutions.(Ongetal.,1995Meryn,1998).(Buston,2002,p.241).ListeningtoYouth&CollaboratingDifferentandDiverseAcrossDisciplines McGorry(2007)reflectingonthepublicmentalhealth Ourhealthsystemneedstotakethenextstepforwardin systeminAustraliastates: removingthebarriersbetweenhealthprofessionalsandyoungpeople.Itneedstostartlisteningtowhatweare Anewyouthmentalhealthapproachisrequiredthatsayingandwhatweareaskingfor.Toknowwhatworksbestforus,thesystemhastobecomeyouthfriendlyand buildson,butisqualitativelydifferentfrom,existingchildyouthoriented.(VictoriaTonin,Platformyouth andadolescentandadultapproaches,whichhavebothparticipationprograme,ORYGENYouthHealth,2007) struggledtoaddressthementalhealthneedsof (McGorry,2007,p.S53). teenagersandyoungadults(McGorry,2007,p.S54). Inordertounderstandwhatsupportsthehealthy Youthmentalhealthservicesneedtoprovideanintensive, developmentofyoungpeopleandthebestapproaches comprehensiveandintegratedserviceresponsetoyoung forpromotingwellbeingweneedtosynthesiseand peopleandtheirfamilies,focusedonsymptomremission, integrateknowledge,notjustfromawiderangeof researchfields,orevendisciplines,butfromacrossthe socialandvocationalrecovery,andrelapseprevention naturalandsocialsciencesandhumanities(Eckersley (McGorry,2007). 2004,p.41).1

2. InterdisciplinaryApproach Muchcanbelearntfromthestudyofhumandevelopment,youthStrengthsBasedSuicidePrevention developmentandyouthwork,nursingandtherapy. Improvingcare,protectionandtreatment Thesedisciplinescontainconcepts,researchandknowledgethat caninformthedevelopmentofastrengthsbasedapproachtoCollaboratingwithyouthtobuildcompetenceandconfidence suicideprevention. Fosteringdevelopmentandwellbeingandaddressingrisk Muchoftheworkinthesedisciplinesisstrengthsbased.Reconnectingyouthwiththeirsocialworldandlife Somekeythemeswithinthesedisciplinesare: YouthLife Nursing Therapeutic Startingwiththeindividualsstrengths.Development HistoriesCare Alliance Participativeprovidingyouthwithopportunitiestotakepart,influence decisionsthataffectthem.Theory Empoweringprovidingyouthwithcompetenceandconfidence. Educativeteachingyouth21stCenturyskillsandknowledgebut acknowledgingtheflowofteachingandlearningbetweenyouthandNursingYouth Human Therapy thosewhosupportthem.WorkDevelopment RelationshipsWhatCanbeLearnedfromYouthDevelopment? Focusingonyoungpeoplesstrengthsrather thantheirfailingsistheunderlyingprincipleof youthdevelopment(MYD,2002). Reducingandpreventingdevelopmentaldeficits andpromotingdevelopmentalstrengthsare parallel,uniqueandcomplimentarytracks. Figure1illustratestherelationshipbetween deficitandstrengthsbasedpolicyorientations. (Benson,Mannes,Pittman&Ferber,2004,p.785)SuicideandSelfharmasSymptomsofCollapsedSocialWorlds ConnectingwithLifeHistories Traditionallyyoungpeoplehave DenovandMaclure(2007)state:beenlabelledasatriskonthe Lifehistoriescanprovidelistenersandreaderswithinsightsintothecourseofbasisofthesymptomsratherhumandevelopmentandtheworkingsofthehumanmind(McAdams2001,thanthecausesoftheirp.307)situation(Martin,2002,p.20). Theuseofalifehistoriesapproachwithyoungpeoplewhohaveengaged Weneedtolookatworlds innonfatalsuicidalbehaviourmayshedlightontheindividuals behaviouroccursin.experiences,choicesmade,actionstaken,andconsequencesfeltaswellasrevealimprtantinformationaboutlocalcontexts,socialstructuresand Interventionsbasedonsymptoms culturalmoresthatinfluenceyoungpeoplesbehaviour.areusuallyonlygoingtoaddressasinglefactor(notgettingthe Lifehistoriesmayalsobeusedtoilluminateturnings(fundamentalshiftsinbiggerinterconnectedpicture).rolesandidentity)andadaptations(alterationsofbehaviourandidentityovertime)(Denov&Maclure,2007)thatmayhelpsuicidalyouth Interventionsbasedonsymptoms understandtheirbehaviour,livesandfindnewwaysofcopingandadapting.leadustolookatwhatiswrongwiththeindividualdeficits Healthprofessionalsmightusealifehistoriesapproachtobothconnectbasedapproach(Martin,2002). withyouth,provideyoungpeoplewithavoiceandfinditausefultoolforbeginningtocollaboratewithsuicidalyouthtofindmeaningandwaysforwardfortheirrecovery. (Martin,2002,p.21) 2 3. LifeTrajectoriesandHumanDevelopment GettingtoKnowYouth Thestudyofsuicidalprofilesacrossthelifetrajectorycanhelpus AsEtherington(2007)states: mapdistinctivepathwaysandbetterunderstandthecumulativeLifestoryresearchcanhelpuscoconstructcomplex,multilayered effectsofriskandprotectivefactors,includingchildhoodadversity narrativeknowledgethatwecanholdalongsidetheparadigmatic andmorerecentevents(Sguin,Lesage,Turecki,Bouchard,knowledgegainedbyusingtraditionalresearchmethods(Bruner, Chawky,Tremblay,Daigle&Guy,2007).1986Mishler,1999Polkinghorne,1988)(p.456). TheuseofLifechartscanhelpintheexaminationoftheduration, Itisnotaboutfindingthecausalexplanationbutabout developmentandcharacteristicsofthesuicidalprocessinyoung howyoungpeoplemakeconnectionsbetweenlife people,particularlywhenbasedonpsychologicalautopsy experiences,healthissues,theirsenseofselfand information(Fortune,Stewart,Yadav&Hawton,2006).identity. Examiningthedevelopmentalinfluencesandtheuniquetrajectories ofyoungpeopleisalsoakeyareawithinthestudyofHuman Ifyouwanttoknowme,thenyoumustknowmystory,formy DevelopmentandtheareaofeducationforHumanServicestorydefineswhoIam.AndifIwanttoknowmyself,togain Professionals(Harms,2005). insightintothemeaningofmyownlife,thenI,too,mustcome toknowmyownstory(McAdams,1993,p.11)(quotedin Etherington,2007,p.456). ReconnectingwithHumanitytoAidRecovery DefiningaTherapeuticAlliance Recentnotionsofrecoveryseemtoencompassa Thetherapeuticrelationship,whetheritexistswithinthecontextoftherapy, processwherebytheindividualcanreclaimhis/herselftreatment,careorsupportcallsforaperspectiveofcollaborationthatenablestheindividualtodefinetheirownneeds,usealanguagethatmakes esteem,pride,choice,dignity,andmeaning(Wright,Haighsensetothemandtheirsignificantotherandempowersthemtotakecontroloftheirlife. &McKeown,2007). Thetherapeuticallianceisimportantforalleviatingasuicidalindividualssenseofpowerlessnesstochangehimselforherselfortheenvironment, Healthprofessionalsneedtoembracepeopleshumanityandfacilitatetheexperienceofsuccessandmasteryindealingwithhis/hersituation. tofacilitatethisprocess. Itallowsthepersontotakeanewperspectiveorstandpoint(Sderberg,2004). Recoveryisaboutthewholeperson,identifyingtheirstrengths, instillinghope,andhelpingtofunctionatanoptimallevelby Itrequiresthepresenceofsignificantotherswhocanreinforcethe allowingthemtotakeresponsibilityfortheirlife(Townsend&individualsnewapproachtotheworld. Glasser,2003,p.83,quotedinWright,Haigh&McKeown, Theserelationshipscarrythepotentialforadevelopmentofselfesteem 2007,p.243)andselfworthandbuildonanactivedecisionandpersonalcommitmentforchange(Sderberg,2004).ConnectingwiththeExpertsYoung WhatCanBeLearnedfromTherapy?People Summer&Barber(2003)notethatthestrengthofthe Suicidalyoungpeoplearevaluablesourcesof collaborativerelationshipbetweenpatientandtherapistexpertiseandknowledgeandthatifpractitionershave hasbeenrecognisedascrucialbytherapistsfrom welldevelopedcommunicationskills,andarewillingto differenttheoreticalbackgrounds.seepastthesuicidalbehaviourtomeettheexpertwithintheindividualtheyaremorelikelytofindthe Establishingthisrelationshipisoftenseenasthefirst answerstowhatthepersonneedstostoptheirsuicidal stepintreatment.behaviourandrecoverandthrive(Crockwell&Burford, Referredtovariouslyastherapeutic,workingorhelping1995). alliance. Bordin(1979)definedithashavingthreecomponents: Theimportanceofestablishingatherapeuticalliance1. GoalsSharedgoals.withthesuicidalpersonisalsosomethingrecognised2. TaskAcceptedrecognitionofthetaskseachpersonisto withinNewZealandguidelines(NZGG,2003)asperfomintherelationship.somethingthatcanfacilitatethedisclosureofinformation3. Bondanattachment.andasenseofhopefulnessandconnectedness.3 4. CollaboratingwithYouthtofind WhatCanBeLearnedfromNursing? Strengths Healthprofessionalsprovidingaftercaresupport,treatmentandcarealso Samuelsson,Wiklander,sberg&Saveman(2000)identifiedthefollowingaspectsof careintheirstudyofpyschiatricinpatientswhohadmadesuicideattempts: needtoseebeyondthesuicidalbehaviourandhelpyoungpeoplediscover Receivingunderstanding,confirmation(sympathy,allowingaction,thosewho orrediscovertheirstrengthsandpotential. mediatedhopeandorientationtowardsthefuture). Understandingthepatientsworldfromtheirpointofviewinordertobeableto WarelowandEdward(2007,p.134)state:rehabilitatehope. Warmthandsupportduringinitialtreatmentstage.Recoveryorimprovementinmentalhealthwasoftenachievedwhen peoplewith Beinginanursescaregivingasenseofsecurity. mentalhealthissuesdiscoverorrediscoverstrengthsandabilitiesforpursuing Confidenceandtrust. theirownpersonalgoalsanddevelopingasenseofselfthatallowsthemtogrow Aeccessibilityknowingtheywerewelcometocontactthewardatanytime. ormovebeyondthesymptomatologythatdeemsthemtohaveamentalillnessin Sensitivitytoneedstheneedtotalkortheneedtobeleftalone. thefirstplace(Edward&Warelow2005p.101) Verbalcontactswithstaff(essentialforhealingandfordesiretogoonliving). WarelowandEdwardarguethatcaringasapracticemayassistpeopleto Whatwasnthelpful: becomemoreresilient. Nurseswhoweremoreinterestedinresearchthanintheperson. Nurseswhotookroleoftheneutralspectatorratherthanthecloseinvolved Psychiatricnurseshaveopportunitiestointerruptanongoingsuicidal fellowcreature. processbyinterveninginsuicideattemptsandprovidingcaretoreducethe Lackofunderstandingofthepatientsperspectiveandnotacceptingthepatients incidenceofsuicide(Samuelssonetal.1997citedinSun,Long,Boore& suicidality. Tsao,2005,p.275). Beingtreatedlikechildren,beingguardedandcontrolled. Notbeingconfirmedledtofeelingsofbeingburdensome,desiretogohome, andfurthersuicideattempts. NursingCareTheory Nursesinthestudyindicatedthey Nursingcaretheorycanguidethenursingcare usededicatednursestoinitiate forpatientsathighriskofsuicide.andmaintainatrusting relationshipwithsuicidalpatients. Dedicatednursesassessed patientssuicidalthoughts,used Sunetals(2005)studyhighlightedtheneedforsuicideindexscalestoassess nursestohavethefollowingskills: thoughtsandfeelings. Advancedcommunicationqualitiesandskillsto:Basiccareincludedbeingthere forpatientsintheirhumanity, Effectivelyandcontinuallyassesssuicidalpatients physicallyandemotionally,in Protecttheirsafety presenceandtime. BethereforpatientstoprovidebasiccareCompassionateartofnursing includedsixconcepts: Usethecompassionateartofnursingtoprovideadvancedcare Empathy,beingnonjudgemental, acceptanceofpatientasperson Facilitatepatientstohealandregaintheirdesiretolive. first,sincerity,kindnessand Figure2 respectfordignity. Action/interactionstrategiesinthenursingcareofpatientswhoaresuicidal(Sunetal.2005,p.278) KeyFindings:Roles,CommunicationSkills&InstillingHope CaringforSuicidalPeople KeyFindingsfromSunetals(2005)study: Nursestakeonmanyroleswhentakingcareofsuicidalpeople: Cutcliffe&Stevensons(2007)bookargues Personcentredcare Educator Counsellor thatnursesneedtomovebeyondobservationalcarebecausethismayonly NurturerConsultant Advocate deferandnotprevent,suicide. Crisismanagement Akeyconceptinthebookisreconnectingthesuicidalperson/patientwithhumanity Effectiveuseofsevencommunicationskillshelpednursesacknowledge andarguesthatnursesneedtoprovide patientsthoughtsandfeelings:suicidalpeoplewith: ListeningandhearingEngagingPerceptiveofmoods Intense,warmhumancontactbecause Opencommunication Facilitatingdisclosure suicidalpeopleareoftendisconnectedfromfamilyandfriendsandlack TouchUseofsilencesupport.Thisstageisaboutbeingwiththeperson. Instillinghopewasrelatedtofourconcepts: Theyneedtomovebeyondthistoalso Encouragingorteachingpositivethinking Promotingselfconfidencechallengingthepatientsideasand ValuingpatientsaspeopleTeachingproblemsolving thoughtsaboutsuicideandguidethepersonbacktolifeaffirmation.Thisstageisaboutdoingand Inordertoachieveallthesenursingcarestrategies,nursesneededto reconnectingthepersonwithpre initiateandmaintaintherapeuticrelationshipswithpatients.suicidalideas,feelingsandhope. Athirdstageinvolvesthesuicidalpersonembracingthehardworkofreinvestinginlife. 4 5. Issues:MicrofacismandtheEvidence Discourse RonaldMaris,intheforewordtoCutcliffeandStevensons Smith(2007)notesthatthereisaneedtobreakdownmicrofacismwhichisatplay inthecontemporaryscientificarena.(2007)book,notesthefollowingpracticeimplicationsoftheauthorsresearch: Microfacismoccurswhenadominantideologyexcludesotherforms ofknowledge.It seekstoprotectaprivilegedstatusbypromotingaregimeoftruth. 1.Nursesneedtobecomfortablewithdeathanddeathtalk. Heclaimsthattheevidencebasedmovementinhealthsciencesisoutrageously exclusionaryanddangerouslynormative. 2.Nursesneedtotalkinordertolisten. 3.Nursestrainingneedstobemorecarefocusedandless Healsonotesthatscholarsnotonlyhaveascientificdutybutanethicalobligationtoassessmentfocused. deconstructregimesofpower. 4.Nursesneedtoengagetheirpatientsandnotmerely Collaborationacrossdisciplinesthatcancontributetosuicidepreventionwillobservethem. bedifficultifsomedisciplinescontinuetoactasfaciststructuresandexclude otherformsofknowledgeincludingthatwhichcomesfromyoungpeople. 5.Thereisaneedtomoveawayfrommedicationbasedtreatment. Communitiesofpractice:whereknowledgeemerges,isexchangedandisco constructedthroughmutualdiscussionandwhereyoungpeoplecanhaveavoice 6.Thereisaneedtomovebeyondsuicideriskassessmentshouldbeencouraged.tosuicidalpatientcare(Marisnotesthatriskassessmentneversavedanyoneslife). Communitiesofpracticearewheresocialandintellectualcapitalarebuiltthrough researchandpracticecommunitiesworkingtogether.Theyarecharacterisedby 7.Arecoverynotacuremodelneedstobeadopted(p.ix). processesofmutualnegotiation,reciprocity,trustandcohesion exist(Smith,2007).Implications Thoseworkingtogethertopreventsuicideandinparticularinthoseyoung Itisimportantforhealthcareprofessionalstobemorethanjust peoplewhohavealreadyengagedinsuicidalbehaviourneedtolookatareasknowledgeabledoers preventionactivitiesneedtobecarriedoutwithin ofcommonalityacrosstheirservicesanddisciplinesandfocusonaspectsof anethicalframeworkofcarewithcompassionandsensitivity care,protectionandtreatmentthatseektoreduceriskandpromotewellbeingotherwiseyoungpeoplewillfeeltheyaretheretobecontrolledrather anddevelopment. thancaredfor. Inclusiveratherthanexclusivecommunitiesoflearningandpractice Thereisaneedtogobeyondofferingbasiccarewhichisimportant, shouldbeencouragedthatdrawuponawiderangeofknowledgeand expertisetoadvancebestpractice,andresearchinformedpracticeand toalsoofferingadvancedandcompassionatecarewhichcoulddraw evidencebasedpractice. onthelearningfromthecompassionateartofnursing. Thereneedstobeamoveawayfromtheunhelpfuldebateaboutprevention Healthandhumanservicesprofessionals(andinparticulartertiary ORpromotion.students)mayneedspecificeducationinsuicideprevention.Thisis somethingthathasbeennotedinsocialworkeducation(Feldman& Researchneedstobeconductedonthebestwaystodevelopanddeliver Freedenthal,2006). integratedcommunityandaftercareservices(particularlyforthoseyoung peoplewithseriousmentalhealthproblems)bymultidisciplinaryteamsthat includenurses,GPs,psychiatrists,counsellors,youthworkers,socialworkers Humanservicesandhealthprofessionalsmayalsobenefitfromsome andeducators. educationfocusingonadolescentandyouthdevelopmentsotheybetter understandtheneedsandworldsofyoungpeopleandtraininginbasic Thereneedstobeagreaterrecognitionthatyoungpeopleoccupymany relationshipskills(Binder,Bongar&Messer,1993citedinSummers& socialworldsandcontextsthatinfluencetheirdevelopment,wellbeingand Barber,2003)andhowtobuildtherapeuticorworkingallianceswith behaviour. youngpeople.SomeConclusions References AssociateMinisterofHealth(2006).TheNewZealandSuicidePrevention Strengthsbasedsuicidepreventioninrelationtoyouth Strategy20062016,Wellington:MinistryofHealth.should: Focusonpromotinghealthyyouthdevelopmentandyouth Benson,P.L.,Mannes,M.,Pittman,K.,Ferber,T.(2004).Youthdevelopment,engagementintheircommunitiesandsocieties.developmentalassets,andpublicpolicy.InR.M.Lerner&L.Steinberg(Eds.) HandbookofAdolescentPsychology(2ndEd.)NJ:JohnWiley&Sons,Inc. Stillacknowledgetheneedtoaddresshealthcompromising (Figure25.1ApproachestoSuccessfulDevelopmentp.785.behaviours,riskfactors,andimprovecrisisintervention,careandtreatment. Buston,K.(2002).Adolescentswithmentalhealthproblems:Whatdotheysay Focusonhealthandhumanserviceprofessionalsworkingwithaboutmentalhealthservices?JournalofAdolescence,25:231242.youthnotonyouth. Crockwell,L.&Burford,G.(1995).Whatmakesthedifference?Adolescent Provideyouthwithgreateropportunitiestodevelopalliances,femalesstoriesabouttheirsuicideattempts.JournalofChildandYouthCare,connectionsandtocollaboratewiththosewhocansupportthem. 10(1):114. Breakdownbarriersbetweenservicesandyouth,fosterthe Cutcliffe,J.R.&Stevenson,C.(2007).Careofthesuicidalperson.China:developmentofyouthfriendlyandyouthfocusedservicesandChurchillLivingstone,Elsevier.modelsoftreatment,careandprotectionandencourageintegratedservicedeliverywithincommunities. Eckersley,R.(2004).Separateselves,tribalties,andotherstories:Making Encouragecollaborationbetweenresearchdisciplinessothatsenseofdifferentaccountsofyouth.FamilyMatters,(68):3642.Australianpeoplecandeveloppartnerships,communitiesoflearningandInstituteofFamilyStudies.Retrieved18February,2007,fromcommunitiesofpractice.http://www.aifs.gov.au/institute/pubs/fm2004/fm68/re.pdf 5 6. Etherington,K.(2007).Theimpactoftraumaondrugusersidentities.British MinistryofYouthDevelopment(2002).YouthDevelopmentStrategyAotearoa. JournalofGuidance&Counselling,35(4):455469.MinistryofYouthAffairs,Wellington:,NewZealand.RetrievedFeb28,2007from http://www.myd.govt.nz/Publications/YouthDevelopment/youthdevelopmentstrategy Feldman,B.N&Freedenthal,S.(2006).Socialworkeducationinsuicideaotearoa20.aspx interventionandprevention:Anunmetneed?SuicideandLifeThreatening Behavior,26(4):467480. 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